Provider Demographics
NPI:1699328393
Name:TIBBE, MARY (MSN RN CCRN-K AGCNS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TIBBE
Suffix:
Gender:F
Credentials:MSN RN CCRN-K AGCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18901 W KIMBALL RD
Mailing Address - Street 2:
Mailing Address - City:PIERSON
Mailing Address - State:MI
Mailing Address - Zip Code:49339-9605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-520-1135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704270663364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology